When people call our office looking for information about long-term care options, we often find that there is a lack of understanding about the differences between Medicare, Medicaid, and Medical Assistance. Karen Scott, the Director of Admissions at Manor Care Health Services in Carlisle, recently shared that some of the families she works with are shocked to find out that Medicare does not automatically pay for all of nursing home care for extended periods of time. Since the names Medicare and Medicaid sound alike, it is easy to confuse the two. As seniors’ health care needs change, planning to pay for health care can become more complicated when families lack a general understanding of these federal programs.
Medicare is the federal health insurance program that is available for people age 65 and older, people who are under age 65 with certain disabilities, and people of any age who have End Stage Renal Disease. This program is supported by premiums and payroll taxes. There are four parts to the Medicare program.
- Part A (Hospital Insurance) – This part covers inpatient hospital stays, temporary stays in a nursing home to receive rehabilitation or skilled care, hospice care, and home health care. In order for Medicare to pay for rehabilitation in a nursing home, an individual must have been admitted to the hospital for at least three nights within the 30 days prior to the nursing home stay. A distinction is made between individuals who are “admitted” versus “held for observation,” so make sure the patient’s status is clarified when in the hospital. If the three night admission qualification is met, be aware that Medicare will cover the first twenty days of a nursing home stay in a Medicare approved facility. After that, there will be a daily copay amount charged to the patient for days 21 – 100. Also note that 100 days isnot guaranteed, the number of days which Medicare will pay for depends on the patient’s condition. In our experience, patients with a traditional Medicare plan through the federal government have a greater chance of receiving more covered days than those with a Medicare plan administered by a private insurance company (see Part C below).
- Part B (Medical Insurance) – This part covers doctor appointments, medical equipment such as a walker, outpatient services (such as therapy), some preventive services, and home health care. Premiums for this coverage are deducted from an individual’s Social Security or Railroad Retirement benefit. To qualify for home health care under Parts A & B benefits, an individual must require intermittent, skilled care from a nurse or therapist, which is ordered by a physician. In addition, the patient must be considered homebound (determined by the physician), and the services must be provided by a Medicare certified agency. Routine personal care and homemaking services are usually not included unless someone is also receiving temporary skilled services.
- Part C (Medicare Advantage Plans) – This part combines both Part A and Part B coverage and is administered by Medicare approved private insurance companies. Some plans will also include Part D coverage (see below). Extra benefits and services may be available as part of the plan or for an additional cost.
- Part D – This part covers the cost of prescription drugs, and is run by private insurance companies.
To find out additional information about Medicare plans and benefits, visit www.medicare.gov.
Medicaid is a combined federal and state program which provides health coverage for people who meet strict income and asset guidelines. Every state has different rules related to Medicaid eligibility. In Pennsylvania, the Medicaid program is called Medical Assistance, so these two terms are used interchangeably here. The Pennsylvania Department of Public Welfare administers this program. Coverage is provided for costs related to hospitalization, nursing home care, doctor visits, medical equipment, home health care, and sometimes medications. While Medical Assistance is often thought of as coverage for those who are low income, this benefit can also be used by middle class families to supplement income to pay for long-term care in a nursing home. There are strict regulations which must be met to qualify for Medical Assistance, and unless one has limited income and assets, the aid of an elder law attorney may be required during the application process. It is important to note that neither Medicare nor Medicaid cover the cost of care in a Personal Care Home or Assisted Living Facility.
As you can see, Medicare and Medicaid are two different programs with varied eligibility requirements and types of benefits. An understanding of these differences can help prevent unwelcome surprises during a health care crisis, and lead to improved planning strategies for potential future needs.
Karen Kaslow, RN, Care Coordinator